Provider Demographics
NPI:1457738064
Name:MAS KOBA, JADE (MD)
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:
Last Name:MAS KOBA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-2060
Mailing Address - Fax:239-424-2061
Practice Address - Street 1:650 DEL PRADO BLVD S STE 100
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-5617
Practice Address - Country:US
Practice Address - Phone:239-424-2060
Practice Address - Fax:239-424-2061
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-04
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA162053207V00000X
FLME171297207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL125173600Medicaid